14 15Solinap&Somongcad D

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QUALITY STANDARD IN HEALTH CARE ORGANIZATION

IMPROVING PERFORMANCE


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Presented to

Dr. Betty T. Polido

Faculty of the College of Nursing

Central Philippine University

In Partial Fulfillment

for the Requirement in the course

N 414- F

By

Solinap, Lady Juelaine M.

Somongcad, Denevieve P.

July 10, 2012


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The report is about improving performance in health care organizations specifically it aims

to:

identify important events and people in the history of quality care;

describe factors influencing performance of health workers and strategic performance;

discuss about ineffective performance and factors related to it;

determine the influence of motivation as a performance indicator

identify strategies that influence, competence and responsiveness among health care

organizations;

compare the benefits and drawbacks of performance appraisal

describe what is Total Quality Management (TQM);

explain the relevance of TQM in Quality of Health Care.

OBJECTIVES:


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Qualityis a more complicated term than it appears. Dictionary definitions are

usually inadequate in helping a quality professional understand the concept. It seems

that every quality expert defines quality somewhat differently, and there are a variety of

perspectives that can be taken in defining quality. This report focuses in improving

performance of health care provider organizations in quality standard.

Improving performance is a very relevant topic in the health care

organization since our clients deserve the best quality of care. We, as the providershave to be fully equipped with knowledge, skills and attitude in order to be considered

as competent in our field.

INTRODUCTION


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The quality movement can trace its roots back to medieval Europe, where

craftsmen began organizing into unions called guilds in the late 13th century.

Until the early 19th century, manufacturing in the industrialized world tended

to follow this craftsmanship model. The factory system, with its emphasis on product

inspection, started in Great Britain in the mid-1750s and grew into the Industrial

Revolution in the early 1800s.

In the early 20th century, manufacturers began to include quality processes in

quality practices.


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After the United States entered World War II, quality became a critical

component of the war effort: Bullets manufactured in one state, for example, had to

work consistently in rifles made in another. The armed forces initially inspected

virtually every unit of product; then to simplify and speed up this process without

compromising safety, the military began to use sampling techniques for inspection,

aided by the publication of military-specification standards and training courses in

Walter Shewharts statistical process control techniques.

The birth of total quality in the United States came as a direct response to

the quality revolution in Japan following World War II. The Japanese welcomed the

input of Americans Joseph M. Juran and W. Edwards Deming and rather than

concentrating on inspection, focused on improving all organizational processes

through the people who used them.


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By the 1970s, U.S. industrial sectors such as automobiles and electronics

had been broadsided by Japans high-quality competition. The U.S. response,

emphasizing not only statistics but approaches that embraced the entire

organization, became known as total quality management (TQM).

By the last decade of the 20th century, TQM was considered a fad by

many business leaders. But while the use of the term TQM has faded somewhat,

particularly in the United States, its practices continue.

In the few years since the turn of the century, the quality movement seems

to have matured beyond Total Quality. New quality systems have evolved from the

foundations of Deming, Juran and the early Japanese practitioners of quality, and

quality has moved beyond manufacturing into service, healthcare, education and

government sector (http://asq.org/learn-about-quality/history-of-

quality/overview/overview.html).


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Poor performance of service providers leads to inaccessibility of care and

inappropriate care, which thus contribute to reduced health outcomes as people are

not using services or are mistreated due to harmful practices. Poor performance

results from too few staff, or from staff not providing care according to standards and

not being responsive to the needs of the community and patients. As Hughes et al.

state: Most performance problems can be attributed to unclear expectations, skills

deficit, resource or equipment shortages or a lack of motivation (Hughes et al., 2002).

These causes are rooted in a failing health system, low salaries, difficult working and

living conditions and inappropriate training.

FACTORS INFLUENCING PERFORMANCE OF HEALTHWORKERS AND STRATEGIES FOR IMPROVEMENT


9/51Figure 1. Framework for Analysis


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This framework was designed using a systemic approach to health worker

performance: situational analysis, intervention (input/process), outputs, effects,

outcome and impact.

The framework shows that determinants of healthworkers behavior (in the workplace) are rooted in

factors relating to:

macro level, or the overall health system, such as resources allocation, planning

and deployment of health workers, current regulatory framework, communication and

decision-making processes, and accountability mechanisms. These can be influenced by

policy-makers and planners in the health sector, as well as other stakeholders at

national level, such as the ministry of finance, ministry of education, professional

associations, civil society groups and funding agencies (health systems level).


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micro level, or the workplace itself (district or facility, etc.), such as availability of

equipment, drugs and supplies, teamwork and human resources management activities.

In principle these can be influenced by local managers, colleagues, patients and other

local partners (health facility level)4.

individual characteristics and living circumstances, such as living in conflict areas or

being a woman or a newly graduated professional. These require specific group

strategies and can be developed locally by managers or nationally by policy-makers and

planners together with other stakeholders (individual level).


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Interventions are designed based on an analysis of the determinants that

influence health workers performance. Implementation of these interventions (inputs

and process) provides outputs (expected results) in terms of improved working

conditions, improved motivation, improved staff retention, etc. These, in turn, result

in the effects of the intervention in terms of measurable improvements on availability,

productivity, competence and/or responsiveness of health workers. The effects

positively influence performance, i.e. the outcome of the intervention, for which the

intervention is not totally accountable. Improved performance in turn contributes to

improved health status.


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There is no linear relationship between determinants and outputs, between

outputs and effects, and between effects and outcomes. Health worker performance is

a complex issue to address, as a variety of determinants influence staff behaviour at

different levels. Various authors have regrouped the determinants (Rowe et al., 2005;

Hongoro & Normand, 2006; WHO, 2006), suggesting four main areas:

health worker characteristics (individual level)

health system and facility characteristics (macro and micro levels)

characteristics of the wider political and socioeconomic environment (contextual

factors)

community/population characteristics (contextual factors)

(www.who.int/hrh/resources/improvinghw-performance.pdf).


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Job performance is ineffective when productivity falls below a standard

considered acceptable at a given time. Ineffective performers consume considerable

managerial time. The causes of poor job performance can be rooted in the employee,

the job, the manager, or the organization. Usually ineffective performance is caused by

a combination of several factors.

Factors contributing to ineffective performance

Employees are or become ineffective performers for many different reasons.

The cause of poor performance can be rooted in the person, the job, the manager, or

the company.

INEFFECTIVE PERFORMANCE


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Insufficient mental ability and

education

Insufficient job knowledge

Job stress or burnout

Low motivation and loafing

Technological obsolescence

Absenteeism and tardiness

Emotional problem or personality

disorder

Alcoholism and drug addiction

Tobacco addiction or withdrawal

symptoms

Conducting outside business on the

job

Family and personal problems

Physical limitations

Preoccupying office romance

Fear of travelling, especially flying

FACTORS RELATED TO THE

EMPLOYEE:


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Inadequate communication about

job responsibilities

Inadequate feedback about job

performance

Inappropriate leadership style

Bullying or intimidating

FACTORS RELATED TO MANAGER :


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Ergonomics problems and repetitive

motion disorder

Repetitive, physically demanding job

Built-in conflict

Night-shift work assignments

Substandard industrial hygiene

A sick building

FACTORS RELATED TO JOB:


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Organizational culture that tolerates

poor performance

Poor ethical culture

Counterproductive work environment

Negative work-group influences

Intentional threats to job security

Violence or threats of violence

Sexual harassment

FACTORS RELATED TO THE ORGANIZATION:


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Define performance standards.

Detect deviation from acceptable

performance

Define and assess the cause

Communicate with the substandard

performance

Set improvement goals

Select and implement an action plan

Reevaluate performance after a time

interval

Continue or discontinue the action plan

(Dubrin, 2006).

APPROACH IN IMPROVING INEFFECTIVEPERFORMANCE:


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Understanding why people do the things they do on the job is not an easy

task for the manager. All important work behaviors are motivated. Managers need to

motivate employees to join and remain in the organization and to exhibit highattendance, job performance, and citizenship.

Motivation refers to forces that energize, direct, and sustain a persons

efforts. All behavior, except involuntary reflexes like eye blinks is motivated. A highly

motivate person will work hard toward achieving performance goals. With adequate

ability and understanding of the job, such a person will be highly productive (Bateman,

2007).

MOTIVATION AS PERFORMANCE INDICATOR


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The Nature of Motivation.

Motivation encompasses the psychological forces within a person that

determine the direction of the persons behavior in an organization, the persons levelof effort, and the persons level of persistence in the face of obstacles. Mangers strive

to motivate people to contribute their inputs to an organization, to focus these inputs

in the direction of high performance, and to ensure that people receive the outcomes

they desire when they perform at a high level.

THEORIES IN MOTIVATION


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Expectancy Theory

According to expectancy theory,

managers can promote high levels of

motivation in their organizations by taking

steps to ensure that expectancy is high

(people think that if they try, they can

perform at a high level, they will receive

certain outcomes) and valence is high (

people desire these outcomes).



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Need Theories

Need theories suggest that to motivate their workforces, managers should

determine what needs people are trying to satisfy in organizations and then ensure that

people receive outcomes that satisfy these needs when they perform at high level and

contribute to organizational effectiveness.

Equity Theory

Managers can promote high levels of motivation by ensuring that people perceive

that there is equity in the organization or that outcomes are distributed in proportion to

inputs. Equity exists when a person perceives that his or her own outcome-input ratio

equals the outcome-input ratio of a referent. Inequity motivates people to try to restore

equity.



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Goal-setting Theory

Suggests that managers can promote high motivation and performance by

ensuring that people are striving to achieve specific, difficult goals. It is important for

people to accept the goals, be committed to them, and receive feedback about how

they are doing.

Learning Theories.

Operant conditioning theory suggests that managers can motivate people to

perform highly by using positive reinforcement or negative reinforcement. Managers

can motivate people to avoid performing dysfunctional behaviors by using extinction

or punishment. Social learning theory suggests that people can also be motivated by

observing how others perform behaviors and receive rewards, by engaging in self-

reinforcement, and by having high levels of self-efficacy.



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Pay and motivation

Each of the motivation theories discussed

alludes to the importance of pay and

suggest that pay should be based on

performance. Merit plans can be

individual,- group-, or organizational

based and can entail use of salary

increases or bonuses (Jones, 2006).


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Various strategies have been developed to improve productivity, competence

and responsiveness of health workers: these range from specific interventions (such as

the provision of performance-related allowances) to more comprehensive approaches

that combine aspects such as training, supervision and the provision of drugs and

guidelines. Success depends not only on identifying and addressing root causes but also

on the process of implementation. Although there was no conclusive evidence, single

interventions often had limited success (Rowe et al., 2005).

STRATEGIES TO INFLUENCE PRODUCTIVITY, COMPETENCE

AND RESPONSIVENESS


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A performance appraisal (PA) or performance evaluation is a systematic and periodic

process that assesses an individual employees job performance and productivity in relation to

certain pre-established criteria and organizational objectives.

A central reason for the utilization of performance appraisals (PAs) is performance

improvement (initially at the level of the individual employee, and ultimately at the level of the

organization). Other fundamental reasons include as a basis for employment decisions (e.g.

promotions, terminations, transfers), as criteria in research (e.g. test validation), to aid with

communication (e.g. allowing employees to know how they are doing and organizational

expectations), to establish personal objectives for training programs, for transmission of

objective feedback for personal development, as a means of documentation to aid in keeping

track of decisions and legal requirements and in wage and salary administration.)

PERFORMANCE APPRAISAL: PROS AND CONS


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Additionally, Performance

Appraisals can aid in the formulation of

job criteria and selection of individuals

who are best suited to perform the

required organizational tasks. A

Performance Appraisal can be part of

guiding and monitoring employee career

development (www.wikipedia.com).



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Potential Benefits of ConductingPerformance Appraisals

Facilitate communication Enhance employee focus by promoting

trust

Goal setting/reinforcement of desired

behavior/performance

Performance improvement

Determination of training needs


Drawbacks of Formal PerformanceAppraisals

Detrimental to quality improvement Negative perceptions

Errors

Legal issues

Performance goals Derail merit pay or performance-based

pay

POTENTIAL BENEFITS OF CONDUCTING


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Facilitate communication:

- recognized as an important skill for managers and leaders in organizations (Kikoski,

1999).

-help reduce employee uncertainty, while promoting more effective communication

between supervisors and subordinates (Spinks, Wells, and Meche, 1999; Wells and

Spinks, 1999).

-absence of feedback leaves employees to play a guessing game concerning whether to

continue on the current path of workrelated behavior or to chart another course.

-encouraging employees to continue on a positive trajectory or to guide employees in

improving problem areas.


PERFORMANCE APPRAISALS



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Enhance employee focus by promoting trust:The existence or the lack of trust among organizational members and

structures affects performance (Argyris, 1964). Behaviors, thoughts, or issues thatdistract the employee from the work task reduce task performance (Kanfer andAckerman, 1989, p. 659). Their reasoning suggested that issues that consume anemployees limited capacity to focus would necessarily lessen the employees ability tofocus on activities that contributed to the achievement of organizational goals.Performance appraisals,properly structured and applied, can be used to help minimizeenvironmental distractions (Mayer and Gavin, 2005), promoting an increased level oftrust within the organization.

Goal setting/reinforcement of desired behavior/performance:

Ideally, organizations strive to match individual goals and performance to theoverall objectives of the organization. This may help reduce uncertainty about job-related expectations (Pettijohn et al., 2001). Performance appraisals also provide aforum for collaboration in setting goals for the employee (Kikoski, 1999). This

collaborative effort in goal setting is desirable because it results in greater acceptanceand satisfaction with appraisal results (Cawley, Keeping, and Levy, 1998).





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Performance improvement:

Performance appraisals are an important tool for communicating with

employees about how well their job-related performance meets organizational

expectations (Spinks et al., 1999). Well structured appraisals should directly relate to

noted improvements in any weak areas (Broady-Preston and Steel, 2002). At the

organizational level, numerous studies have reported positive relationships between

human resource management (HRM) practices, including performance appraisal and

organizational performance (e.g., Arthur, 1994; Delery and Doty, 1996; Guthrie, 2001;

Juselid, 1995; MacDuffie, 1995).





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Determination of training needs:

Employee training and development are crucial components in

helping an organization achieve strategic initiatives (Twomey and Harris,

2000). Seldon et al. (2001) argue that the key to an effective performance

appraisal system is providing individuals with an opportunity to pursue

training and development directly related to problem areas identified in the

appraisal. Appraisals systems can serve as an effective conduit for identifying

training needs, particularly for new employees (Broady-Preston and Steel,

2002). Further, performance appraisals may be useful in establishing and

monitoringemployees career goals (Spinks et al., 1999) (www.asq.org.).




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Despite all the potential advantages of formal performance appraisals (PAs),

there are also potential drawbacks. It has been noted that determining the relationship

between individual job performance and organizational performance can be a difficult

task. These includes:

Detrimental to quality improvement:

It has been suggested that the performance appraisal systems of

organizations are an impediment to the pursuit of quality (Soltani, 2005). Kikoski

(1999) acknowledged the belief among some scholars and practitioners that total

quality management eliminates the need for formal performance appraisals.

DRAWBACKS OF FORMAL PERFORMANCE

APPRAISALS


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Negative perceptions:

Deming (1986), advocated that organizations take steps to create an

organizational environment that was free from fear, thus enhancing the overall quality

of performance. Quite often, individuals have negative perceptions of performance

appraisals (Pettijohn et al., 2001). Indeed, receiving a performance appraisal can be an

unnerving and even frightening experience for some employees (Spinks et al., 1999).

Performance appraisals can also create tension between supervisors and

subordinatesm(Jenks, 1991). This could be why some managers dread or even avoid

conducting them (Kikoski, 1999).


APPRAISALS


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Errors:

Performance appraisals should be based on a pre-established set of criteria

directly related to the employees job assignments (Amsterdam, Johnson, Monrad, and

Tonnsen, 2005). Thus, the ratings should provide an accurate reflection of the

employees performance. However, supervisors often give employees ratings that

exceed their true performance to avoid conflicts or avoid other unpleasant

consequences. Inflated ratings are a common malady associated with formal

performance appraisals (Martin and Bartol, 1998).


APPRAISALS


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Legal issues:

Performance appraisals that are not done well by supervisors can be costly to

organizationsfrom a legal standpoint (Jenks, 1991). This is important since

performance appraisals are becoming increasingly important tools in organizations

disciplinary programs (Spinks et al., 1999). Ratings on performance appraisals may also

be used by some organizations as a basis for promotion decisions. If the appraisals are

not donecorrectly, the resulting decisions may have negative effects on employees, thus

leading to legal action.


APPRAISALS


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Performance goals:

Performance or outcome goals are often used in conjunction with performance

appraisal systems. When performance or outcome goals are too challenging or

overemphasized at the expense of ethics, legal requirements, or quality, this can have

negative consequences for organizations (Loomis, 2003; Schweitzer, Ordonez, and

Douma, 2004). Furthermore, specific challenging performance goals have a deleterious

effect on employees effectiveness in the early stages of learning (Kanfer and Ackerman,

1989). Therefore, in organizational situations where the acquisition of knowledge and skill

is the primary focus, performance goals may be detrimental to performance (Seijts and

Latham, 2005). Learning goals, rather than performance goals would be more appropriate

in these situations.


APPRAISALS


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Derail merit pay or performance-based pay:

Some researchers argue that failure of merit-based pay and performance-

based pay can been associated with problems inherent in performance appraisal

systems (Selden, Ingraham, and Jacobson, 2001). As Milkovich and Newman (2005)note, performance measurement and performance management are the oil that

lubricates the human resources (HR) engine. To determine if HR efforts are working,

accurate performance appraisals are needed (http://asq.org/quality-

participation/2007/03/human-resources/critical-examination-performance-appraisals.pdf).


APPRAISALS


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The TQM concept was developed by a number of American management consultants, including W.

Edwards Deming, Joeseph Juran, and A.V. Feigenbaum. Originally, these consultants won few

converts in the United States. However, managers in Japan embraced their ideas enthusiastically and

even named their premier annual prize for manufacturingexcellence after Deming.

Total Quality Management is a philosophy or approach to management that is grounded on three core

principles:

1. A focus on the customer.

2. Participation and teamwork

3. Continuous Improvement

These principles are supported and implemented by an integrated organizational infrastructure, a set of

management practices, and a wide variety of tools and techniques, which all must work together

and support each other .


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Figure 3. The Scope of Total Quality Management


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The modern definition of quality

centers on meeting or exceeding customer

expectations. Thus, the customer is the

principal judge of quality. Perceptions of

value and satisfaction are influenced by

many factors throughout the customers

overall purchase, ownership and service

experiences.

CUSTOMER FOCUS


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When managers give employees the tools to make good decisions and the

freedom and encouragement to make contributions, they virtually guarantee that better

quality products and production processes will result. Employees allowed to participate-

both individually and in teams- in decisions that affect their jobs and the customer can

make substantial quality contributions. In any organization, the person who bestunderstands his or her job and how to improve both the product and the process is the

one performing it. By training, employees think creatively and rewarding good

suggestions, managers can develop loyalty and trust.

Another important element of total quality management is teamwork, whichfocuses attention on customer-supplier relationships and encourages the involvement of

total workforce in attacking systemic problems, particularly those that cross functional

boundaries.

PARTICIPATION AND TEAMWORK


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TQM requires horizontal coordination between organizational units.

Poor quality often results from breakdowns in responsibility that occurs when

an organization focuses solely on vertical structures, and fails to recognize the

horizontal interactions. Vertical structures lead to internal competition ratherthan promoting the good of the whole organization.

Partnerships are an additional way of promoting teamwork.

Partnerships between a company and organized labor and between customers

and suppliers are common among companies practicing TQM.


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Continuous Improvement has its roots inthe industrial revolution. In the early 1900s, Frederick

Taylor, often called the Father of Scientific

Management, believed that management had a

responsibility to find the best way to do a job and

train workers in the appropriate procedures.

Continuous improvement is an integral

part of the management of all systems and

processes. Under TQM framework however,

responsibility for quality lies with the individual

worker and teams of workers and quality is the

principal focus. The process of continuous

improvement requires systematic planning, execution,

and evaluation.

CONTINUOUS IMPROVEMENT


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Improvement is a critical aspect of all operations and of all work unit

activities of a company. Improvements may take any one of several forms:

Enhancing value to the customer through new and improved products and

services

Reducing errors, defects and waste

Improving productivity and effectiveness in the use of all resources

Improving responsiveness and cycle time performance

Seven important principles of Total Quality


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1. Quality can and must be managed

2. Processes, not people, are the problem

3. Dont treat symptoms, look for the cure

4. Every employee is responsible for quality

5. Quality must be measurable

6. Quality improvements must be continuous

7. Quality is a long-term investment

(http://managementhelp.org/quality/total-quality-management.htm).

Seven important principles of Total Quality

Management as a foundation for all your activities

APPLICATION OF TQM IN QUALITY OF


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Total quality management (TQM) is originally a concept of manufacturing

management. It is first used in the enterprise management, and considerrd as one of effective

methods of managing in the management field because a good result is achieved on TQM.

One of the content of its core is based on the course of the total quality management.

The total quality management thinking applied to the management of hospital careis to focus on the hospital care management, improve work-related activities, and establish

apatient-centeredconcept of care, so that the management of all hospital care forms a

complete network of services, which will ensure and enhance the quality of care. Hospital

care is an important component of the overall curative work. The quality of care reflects the

work level of hospital care and the quality of hospital management, and directly relates to the

patients life and health, impacts the satisfaction degree of the patient on the care, and even

plays a vital role in the development of the hospital (http://www.res-medical.com/clinical-

medicine/81208).

APPLICATION OF TQM IN QUALITY OFHEALTH CARE


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Achieving quality care and improving performance is not an instantaneous job to do.

This two requires endless effort to be achieved. Before achieving that certain level of excellence

in patient care there are certain factors to consider.

In improving performance, various factors influencing staff retention and mobility

can be distinguished such as personal and lifestyle-related factors, including living circumstances;

work-related factors, related to preparation for work during pre-service education; health-systemrelated factors, such as human resources policy and planning; and job satisfaction, influenced by

health facility factors, such as financial considerations, working conditions, management capacity

and styles, professional advancement and safety at work. providers depends on the political,

socioeconomic and cultural environment.

As elements influencing performance are intricately related to each other,

interventions must be comprehensive and multifaceted and must take place simultaneously and at

different levels of the health system. While experiments have taken place using different types of

interventions to improve performance of health workers, substantive evidence of their

effectiveness is still limited.

LESSONS LEARNED


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Books

Bateman, Thomas S (2007). Management: leading & collaborating in a competitive world . The

McGraw-Hill Companies, Inc., 1221 Avenue of the Americas, New York,NY,10020 :p. 427-428

DuBrin Andrew J. (2006). Essential of Management, Seventh Edition . Thomson HigherEducation 5191 Natorp Boulevard Mason, OH 45040 USA: p. 513, 538

Evans James R., Lindsay William M. (1996). The management and control of quality ,West PublishingCompany 610 Opperman Drive P.O. Box 64526 St. Paul, MN 55164-0526: p.105-109

Jones,Gareth R (2006).Contemporary Management , The McGraw-Hill Companies, Inc., 1221 Avenueof the Americas, New York,NY,10020: p.484

Electronic Resourceswww.who.int/hrh/resources/improvinghw-performance.pdf (07-8-2012)

http://asq.org/learn-about-quality/history-of-quality/overview/overview.html (07-8-2012)

http://asq.org/quality-participation/2007/03/human-resources/critical-examination-performance-appraisals.pdf (07-8-2012)

http://www.res-medical.com/clinical-medicine/81208. (07-8-2012)

BIBLIOGRAPHY

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14 15Solinap&Somongcad D